ATLS primary survey — the unstable blunt polytrauma patient

The survey itself. Parallel and goal-oriented, not serial: with a team, airway with cervical spine protection, breathing, circulation with haemorrhage control, disability and exposure run simultaneously, with defined endpoints for airway management, access and haemodynamic parameters.^[1] The reduced air entry with hypoxia and hypotension is tension physiology until excluded — treat, don't image.

Needle decompression — say the numbers. Immediate needle decompression followed by an intercostal drain. The 2025 meta-analysis pooled 24 studies and 8,046 patients: a 32.84% failure rate, failure falling 7.76% per centimetre of needle length, a 7 cm needle appropriate at the 5th midaxillary or 2nd midclavicular site, and — because this is the left side — the 2nd midclavicular line is preferred given cardiac injury risk at the left lateral sites. Then I reassess: a failed needle means finger thoracostomy and a tube, not patience.^[2]

The pelvis — mechanical control with honest evidence. A binder goes on now; WSES grounds pelvic management in haemodynamic status, ring anatomy and associated injuries, multidisciplinary from the start.^[3] But I volunteer the weakness: the 2025 systematic review found no clear superiority of early binder application for mortality (17.4% vs 15.7%), transfusion, pain or complications.^[4]

If he arrests — HOTT, then the REBOA conversation. Traumatic cardiac arrest is managed by immediate, simultaneous treatment of reversible causes: hypovolaemia, oxygenation, tension pneumothorax, tamponade — HOTT.^[7] On REBOA I narrate the inversion: observational meta-analysis favoured it over thoracotomy, but the UK-REBOA randomised trial found higher 90-day mortality with REBOA (54% vs 42%; OR 1.58), and EAST's 2025 guideline conditionally recommends against REBOA for haemodynamically unstable patients with suspected subdiaphragmatic haemorrhage — while conditionally recommending it precisely here, in arrest from subdiaphragmatic bleeding.^[5][6]